Is voluntary male medical circumcision still cost-effective in the setting of antiretroviral therapy scaleup in sub-Saharan Africa?
Authors: David Serwadda, Godfrey Kigozi
Journal: The Lancet Global Health (2023)

Voluntary medical male circumcision (VMMC) has been part of the combined biomedical HIV prevention intervention strategies since January, 2007, when WHO/UNAIDS recommended it as one of the strategies to reduce HIV acquisition in sub-Saharan Africa.1WHOPreventing HIV through safe voluntary medical male circumcision for adolescent boys and men in generalized HIV epidemics: recommendations and key considerations. World Health Organization, Geneva2020Google Scholar Since then WHO estimates that, between 2008 and 2020, more than 26·8 million VMMC procedures have been carried out in 15 priority countries in sub-Saharan Africa.2AIDSSteady progress in the scaleup of VMMC as an HIV prevention intervention in 15 eastern and southern African countries before the SARS-CoV2 pandemic. Joint United Nations Programme on HIV/AIDS, Geneva2021Google Scholar However, during the same period, there has been a massive increase to 25·7 million people living with HIV, with 16·3 million on antiretroviral therapy (ART).3WHO Africa Regionhttps://www.afro.who.int/health-topics/hivaidsDate accessed: December 14, 2022Google Scholar Furthermore, pre-exposure phylaxis is becoming widely available. There is programme evidence that ART has effectively reduced HIV incidence,4UNAIDSUNAIDS Data.https://www.unaids.org/sites/default/files/media_asset/JC3032_AIDS_Data_book_2021_En.pdfDate: 2021Date accessed: December 14, 2022Google Scholar, 5PEPFARPEPFAR 2020 Country Operational Plan Guidance for all PEPFAR Countries. 2020.https://www.state.gov/wp-content/uploads/2020/01/COP20-Guidance_Final-1-15-2020.pdfDate: 2020Date accessed: December 14, 2022Google Scholar and the cost per patient per year has substantially declined. It is against this background that one can start to question the cost-effectiveness of VMMC in Africa. Loveleen Bansi-Matharu and colleagues6Bansi-Matharu L Mudimu E Martin-Hughes R et al.Cost-effectiveness of voluntary medical male circumcision for HIV prevention across sub-Saharan Africa: results from five independent models.Lancet Glob Health. 2023; 11: e244-e255Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar in this issue of The Lancet Global Health examine the cost-effectiveness of VMMC for HIV prevention in the era of increasing ART coverage over a 5-year, 20-year, and 50-year time period, starting from 2021 in several African countries. The strength of this study includes the use of five independent standard models (Optima HIV, EMOD, Thembisa, Goals-ASM, and HIV Synthesis) with different features and assumptions in 15 African countries with different HIV incidence, circumcision coverage, and projected ART use. The models produce fairly similar conclusions over the 5-year projection. Findings beyond 5 years are mixed and inconclusive. The authors conclude that continuing VMMC programmes for 5 years will have a beneficial population health impact in men aged 15 years and older, and are cost-effective or cost-saving in almost all HIV incidence settings in the study over a period of 50 years. Most importantly the benefit is realised in countries with high and low HIV incidence. The findings will particularly be reassuring to policy makers, implementing institutions, and development partners regarding the usefulness of VMMC to HIV prevention efforts in the next 5 years as ART coverage continues to increase. The models compare the continuation of VMMC beyond July, 2021, and no further VMMC beyond July, 2021. This provides an opportunity to evaluate what will happen if VMMC programmes are discontinued for any reason. All models show that the reduction in HIV incidence will be lower in all settings if VMMC is discontinued. To mitigate this and further maximise the observed cost-effectiveness and promote sustainability, there is a need to integrate VMMC and other HIV prevention interventions into government-led programmes. This process is, however, yet to be fully realised in many sub-Saharan countries. A breakdown or end to financing of these prevention programmes will greatly affect progress towards epidemic control, as reflected in the no further circumcision arm of this study, where circumcision is assumed to have ceased after July, 2021. The authors also point out that they cannot make a conclusive projection of cost-effectiveness beyond 5 years. However, a rapid decline in HIV incidence projected in the Optima model between 2020 and 2030 could make VMMC less cost-effective for HIV prevention. This projection probably points to a need to re-evaluate cost-effectiveness in rapidly declining HIV incidence. One of the limitations of this study is that some models assume that non-medical male circumcision, including traditional male circumcision, reduces female-to-male transmission of HIV by the same amount. This assumption can be misleading given the wide range of definitions for traditional male circumcision (ie, complete, partial, or no skin removal), which might lead to wrong assumptions about the efficacy of traditional VMMC. In addition, it is also not clear if religious circumcision (eg, khitan in Islamic culture) is considered part of traditional circumcision. This could be important, especially in communities where Islam is prevalent. In summary, VMMC is still a useful HIV prevention strategy for the next 5 years. There is, however, a need to reassess its cost-effectiveness before the 5 years elapse. We declare no competing interests. Cost-effectiveness of voluntary medical male circumcision for HIV prevention across sub-Saharan Africa: results from five independent modelsVMMC remains a cost-effective, often cost-saving, prevention intervention in sub-Saharan Africa for at least the next 5 years. Full-Text PDF Open Access